Annals for Hospitalists - September 2023
Authors: David A. Fried
Journal: Annals of Internal Medicine (2023)

Web ExclusivesSeptember 2023Annals for Hospitalists - September 2023FREEDavid A. Fried, MDDavid A. Fried, MDFrom University of Michigan, Ann Arbor, Michigan (D.A.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202309190 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Highlights of Recent Articles From Annals of Internal MedicineComparative Safety Analysis of Oral Antipsychotics for In-Hospital Adverse Clinical Events in Older Adults After Major Surgery: A Nationwide Cohort StudyAnn Intern Med. 2023;176:1153-1162. Published 5 September 2023. doi:10.7326/M22-3021This retrospective cohort study (n = 17 115) of adults aged 65 years and older undergoing major surgery evaluated the risk for in-hospital adverse events related to use of the antipsychotics haloperidol, olanzapine, quetiapine, and risperidone. The risk for in-hospital death, cardiac arrhythmia, pneumonia, and stroke or transient ischemic attack did not differ between medications. The study excluded patients who received an antipsychotic the day of or day before surgery, those who had a diagnosis commonly associated with antipsychotic use (such as schizophrenia), as well as those who received intravenous or several different antipsychotics.Key points for hospitalists include:In a population of older postoperative patients, this study found that 4 different antipsychotics conveyed similar rates of in-hospital death and other complications.The study could not determine the indication for antipsychotic use.The Premier Healthcare Database provides diagnosis codes, which may have led to underdiagnosis of in-hospital complications.Cross-Sectional Analysis of Out-of-Pocket Payments for Commonly Prescribed Generic Medications Versus Discount Card PricingAnn Intern Med. 2023;176:1282-1285. Published 5 September 2023. doi:10.7326/M23-0644This descriptive, cross-sectional study compared out-of-pocket drug costs with discount card prices (Amazon Prime and GoodRx) for the 20 most-prescribed generic medications (excluding controlled substances). The authors found that out-of-pocket costs were higher for 20% of the drugs compared with Amazon Prime and 42.6% of the drugs compared with GoodRx. These differences were higher during the estimated deductible phase (39.9% and 79%, respectively). The difference in cost was lowest for Medicare insurances and highest for uninsured patients.Key points for hospitalists include:Patients can save money by using drug discount cards, but it varies depending on insurance, medication, and pharmacy.This study used 2020 out-of-pocket costs and compared them with 2023 discount card costs, which may have affected the results.Standards and Ethics Issues in the Determination of Death: A Position Paper From the American College of PhysiciansAnn Intern Med. 2023;176:1245-1250. Published 5 September 2023. doi:10.7326/M23-1361The American College of Physicians (ACP) published the following recommendations regarding the medical determination of death:Key points for hospitalists include:The ACP recommends changing the Uniform Determination of Death Act to replace the word “irreversible” with “permanent” in relation to cessation of cardiopulmonary function. This serves to clarify situations where a patient with a do-not-resuscitate order has a potentially reversible cause of cardiac arrest, but resuscitation is not attempted in agreement with their previously stated wishes.The ACP supports maintaining the separation of circulatory and brain death standards.The ACP recommends retaining the whole brain standard for determination of death rather than adopting “higher brain” function standards (which state that only the loss of the capacity for consciousness and the ability to breath are required for the determination of death).The ACP advises against recommending specific medical tests for use in determination of death because testing may change in the future and testing may not be equally available across states and institutions.The ACP supports maintaining the separation between death determination and organ transplantation and maintains upholding the dead donor rule (which states that organ donation cannot be the cause of death and that death cannot be caused for the purpose of organ donation).The ACP recommends expanding education opportunities for clinicians and the general public regarding the topic of death determination to reduce misunderstandings.The Latest Highlights From Journal ClubShould noncritically ill patients hospitalized with COVID-19 receive therapeutic or prophylactic dose anticoagulation?In noncritical COVID-19, therapeutic vs. prophylactic anticoagulation did not reduce a composite adverse clinical outcome at 30 dAnn Intern Med. 2023;176:JC93. doi:10.7326/J23-0059This randomized controlled trial (n = 3452) of adults admitted to non–intensive care unit floors for COVID-19 showed that treatment with therapeutically dosed enoxaparin or apixaban did not improve a 30-day composite outcome when compared with prophylactically dosed enoxaparin. Therapeutic anticoagulation though was associated with fewer in-hospital deaths (4.9% vs. 7.0%) and intubations (6.4% vs. 8.4%).Does a hypotension-avoidance strategy improve postoperative outcomes?In noncardiac surgery, hypotension- vs. hypertension-avoidance strategies did not differ for 30-d major vascular complicationsAnn Intern Med. 2023;176:JC90. doi:10.7326/J23-0056This randomized controlled trial (n = 7490) of patients with a history of hypertension undergoing noncardiac surgery found that a perioperative hypotension-avoidance strategy (intraoperative mean arterial pressure ≥80 mm Hg and only giving antihypertensives for systolic blood pressure ≥130 mm Hg) did not lead to improved outcomes compared with a hypertension-avoidance strategy (intraoperative mean arterial pressure ≥60 mm Hg and continued use of all previously prescribed antihypertensives).Do opioids reduce dyspnea symptoms in patients with congestive heart failure?In adults with HF, opioids do not reduce refractory breathlessness (low-certainty evidence)Ann Intern Med. 2023;176:JC88. doi:10.7326/J23-0051This systematic review and meta-analysis of 8 randomized controlled trials (n = 165) of patients with heart failure found that opioids did not improve dyspnea symptoms (standardized mean difference, 0.03 [95% CI, −0.21 to 0.28]) but did increase vomiting (number needed to harm, 28 [CI, 7 to 607]) and constipation (number needed to harm, 4 [CI, 2 to 16]).For patients with atrial fibrillation, does renal function modify the efficacy and safety of direct oral anticoagulants (DOACs)?In AF, the effects of DOACs vs. warfarin on death and stroke/systemic embolism vary by baseline CrCl levelAnn Intern Med. 2023;176:JC91. doi:10.7326/J23-0054This meta-analysis of 4 randomized controlled trials (n = 71 683) compared standard-dose DOACs versus low-dose DOACs versus warfarin and stratified results across renal function. Standard-dose DOACs when compared with warfarin reduced stroke/systemic embolism, intracranial bleeding, and death down to a creatinine clearance of 25 mL/min. Low-dose DOACs in patients with creatinine clearance less than 42 mL/min increased risk for death compared with use of standard-dose DOACs without improving bleeding rates.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David A. Fried, MDAffiliations: From University of Michigan, Ann Arbor, Michigan (D.A.F.)Disclosures:The author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-1807. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics September 2023Volume 176, Issue 9 ePublished: 19 September 2023 Issue Published: September 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.Loading ...